OFFICE OF STUDENT HEALTH Student Immunization Form
To maintain the health of all students, New York State public health law requires that students attending postsecondary institutions in the state
submit proof of immunization against certain vaccine preventable diseases. Students who do not meet these requirements may be unable to
register for courses or to enter campus buildings.
Part 1: Student Information
Student’s Name_____________________________________________________________ Date of Birth________________ /_____________ /______________
YU ID#____________________________________________________________________ School/Program__________________________________________
Email______________________________________________________________________ Phone__________________________________________________
Part 2: Measles, Mumps, and Rubella
All students born on or after January 1, 1957 are required to demonstrate immunity to measles, mumps, and rubella by presenting proof of having received two
vaccinations for Measles (Rubeola), at least one vaccination for Mumps, and at least one vaccination for Rubella (German Measles), or if given in combination,
two MMR (Measles, Mumps and Rubella) vaccines. Immunity may also be affirmed by providing the results of a laboratory test (immune titer) for each disease
and a copy of the lab report. Please complete either 2(A), 2(B) or 2(C) below.
Two Measles, Mumps, and Rubella (MMR) Vaccinations (Attach Documentation)
2A 1st MMR Dose: Immunization no more than 4 days prior to student’s first birthday Date____________________________
2nd MMR Dose: Immunization at least 28 days after first vaccination Date____________________________
Individual Measles, Mumps, and Rubella Vaccinations (Attach Documentation)
1st Measles Dose: Immunization no more than 4 days prior to student’s first birthday Date____________________________
2B 2nd Measles Dose: Immunization at least 28 days after first vaccination Date____________________________
Mumps: Immunization no more than 4 days prior to student’s first birthday Date____________________________
Rubella: Immunization no more than 4 days prior to student’s first birthday Date____________________________
Titer Showing Positive Immunity (Must Attach Laboratory Report)
Note: Titer results that are “Negative” or “Not Immune” are not acceptable. Complete 2A or 2B instead.
2C Measles Date____________________________
Mumps Date____________________________
Rubella Date____________________________
Part 3: Meningococcal Meningitis Vaccination Response Form
New York State public health law requires all college and university students enrolled for at least 6 semester hours or the equivalent per semester, or at least
4 semester hours per quarter, to complete and return this section.
Information about meningococcal meningitis and vaccination is available at:
[Link] or [Link]
Please check one response box below, and sign and date. (Must have attached documentation, or be completed and signed by a
healthcare provider.)
I have:
□ had the meningococcal meningitis immunization (Menactra®, Menveo®) within the past 5 years. Date Administered: ______________
□ read the information regarding meningococcal meningitis. I will obtain immunization against meningococcal meningitis within 30 days from my
private healthcare provider.
□ read the information regarding meningococcal meningitis. I will not obtain immunization against meningococcal meningitis.
Student’s signature__________________________________________________________________________ Date____________________________________
Student (if 18 years or older), otherwise parent
Part 4: Healthcare Provider Information
This form must be signed and stamped by a healthcare provider OR have attached immunization records for all above immunizations.
Provider Name_____________________________________________________ Provider Signature________________________________________________
(Include Office Stamp)
Completed forms should be uploaded within your admissions application in the Supplemental Items section at [Link]
For further assistance, please email YUHealthCenter@[Link] or call us at 646-592-4290.
5-14-2024
